Today’s Date__________________ starting date (Office Use) ______________________________________

Child full name__________________________________________________________________________

Child’s date of birth_______________________________________________________________________
Child’s SS# (DHS)________________________________________________________________________
What does the child like to be called?___________________________________________________________
(If military we need your company name and First SGT Name
With two phone numbers this is for emergency only_________________________________________________

_____________________________________________________________________________________
All phone number please list area code
Parents:
Name of Father_________________________________________________________________________
Email address __________________________________________________________________________
SS #____________________________ or ___________________________________________________
DRIVERS LICENSE NO. & STATE____________________________________________________________
Address_______________________________________________________________________________
Home phone______________________ or _________________________Cell _______________________
Where employed_________________________________________________________________________
Work phone Number_______________________ (2) ____________________________________________
Work Hours____________________________________________________________________________

Name of Mother ______________________________________________________________________
Email address ________________________________________________________________________
SS #_______________________
DRIVERS LICENSE NO. & STATE_________________________________________________________
Address____________________________________________________________________________
Home Phone_________________________ or ______________________Cell _____________________

Where employed______________________________________________________________________

Work phone Number__________________________ (2) ______________________________________
Work Hours_________________________________________________________________________
If parents are divorced, which parent has custody of child?

For the child’s safety, list other persons to whom the child may be released to and the relationship:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Emergency Information:

Name of person, other than operator, authorized to act for parent in an emergency:
They must be local within this town.

Name(1)_______________________________________________________________________

Address________________________________________________________________________

Home Phone__________________________or _________________cell phone _________________

Where employed__________________________________________________________________

Work phone________________________________ or __________________extension __________

Supervisors name and number ________________________________________________________

Work hours and what days ___________________________________________________________

Name(2)________________________________________________________________________

Address________________________________________________________________________

Home Phone_________________________or _____________________cell phone ______________

Where employed__________________________________________________________________

Work phone______________________________ or ________________extension ______________

Work hours and what days ___________________________________________________________

CHILD’S HEALTH HISTORY CHECKLIST

__________________________ ______________ ______________________________________
Child’s name Birth date Parent or guardian’s name

_______________________________________________________________________________
Child’s Physician name Phone

_______________________________________________________________________________
Address here locally

Child’s Dentist name ________________________________________________________________
Phone

Address here locally_________________________________________________________________

The answer to these questions will help us to know if your child has any medical problems.
We need this information in case he/she should become ill and we would be unable to reach you right away.
Please circle the right answer.
We will go over the checklist with you when you have finished if needed.

¬¬¬¬Pregnancy and Birth¬¬¬¬

Yes No Were there any problems with pregnancy or your child’s birth? If so what?
_______________________________________________________________
_______________________________________________________________
Yes No Was his/her birth weight under 5 1/2 pounds? If so why?
______________________________________________________________
______________________________________________________________
Yes No Did the baby have any Medical problems in the hospital if so what?
______________________________________________________________
Yes No Has your child ever been in the hospital overnight? If so why?
______________________________________________________________
How long ago was it? _______________________________________________
Yes No Is your child taking any medicine? If so what ______________________________
What is it for __________________________________________________________?
Yes No Any allergies or reactions to medicine, DTP or other shots, or insects?
If so what? ____________________________________________________________
How does it react to them? _________________________________________________
Yes No Has your child had asthma or wheezing? ____________________how long ago
____________________________________________________________________
do they take medicine for it, if so what _________________________________________
How many times a day? ___________________________________________________
Yes No Does your child have speech or hearing problems?
Yes No Has your child had more than two ear infections in a year?
Yes No Has your child had tonsillitis? if so when ____________________________________
Yes No Does your child have trouble with his/her eyes or seeing?
Yes No Has your child had a bladder or kidney infection? If so when ______________________
Yes No Does he/she have burning when urination? If so why ___________________________
Yes No Does he/she have seizures, fits or shaking spells? If so why, How long does it usually
Last? __________________________________________________________________
_______________________________________________________________________
Yes No Have you ever been told your child has a heart murmur? Is this dangerous yes or no.
Do you wish to comment on this? ___________________________________________
Yes No is your child able to play as hard as other children?
Yes No Has your child ever had a bumpy, swollen reaction to the TB skin test? If so why
___________________________________________________________________.
Yes No Has your child ever been with anyone having TB? If so when ________________
Yes No Has your child ever had worms? If so when? ____________________________
Yes No Does your child scratch his/her genital area/ is his/her bottom or genitals red or sore? If so why? _______________________________________

Yes No Is your child a hemophiliac (free bleeder)? If so why? _______________________
__________________________________________________________________
Yes No Is your child on a heart monitor? If so why? _____________________________
Yes No Does your child have tubes in his/her ears?
Yes No Is your child in a special education class in school? If so why __________________
How can we help? _____________________________________________________
Yes No Does your child get along with other children? If not why? ____________________
___________________________________________________________________
Yes No Is he/she usually happy? If no why? ___________________________________
___________________________________________________________________
Yes No Does you child have any special problems not indicated above? If so what __________
___________________________________________________________________
How can we help? ______________________________________________________
___________________________________________________________________
When did your child last see a doctor? ____________________ for what reason
___________________________________________________________________
Yes No Has your child ever been put out of Daycare etc for behavior. If so what is
The behavior__________________________________________________________
Yes No Does your child have a temper and how do they act when its triggered ! ___________
________________________________________________________________________

Is there any other things that is not listed we should know about?? If so please list.
_______________________________________________________________________________

Does your child have recurring chronic illness or health problems such as, please check the following that apply.
______asthma cerebral palsy ________ developmental delay _________
______diabetes frequent earaches _________ hemophilia ___________
______ seizure others please name and explain _____________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
If there is any additional information we haven't ask for and it is vital to care for your child and maybe a safety issue for other children please list here.
If your child is any way aggressive toward others we need this include biting, hitting, fighting or other issues.
____________________________________________________________________________________

If you desire bug spray or sunscreen on your child please apply before bring them.
I or We have read the policy and we understand or have asked questions, about anything we do not understand.
I herby authorize the center to provide
Emergency medical care.
I have received a summary of licensing re-
Requirements.
___________________________________________

___________________________________________
Parent’s Signature of both parent

Below is a list of things you need to bring for the day. You only have to fill out the application once. But you must keep us up dated on all information. Especially phone numbers, cell number, and work numbers.
You must pay when you drop the children off or we can not care for them, we do not accept checks - cash only! .
Call for drop in price. If there are a couple or a few days during the month and you would like to lock those spots up you must pay for them now. The spots isn't locked until you pay.

Update shot record(just call the doctor an request the shot record on a daycare form) it free.
Each time your child visits the doctor for update shots, exam or physical please take the shot record so they can put up date information on the record.
If this is an emergency drop in care, call the doctor and have them fax me the shot record (this is the only time we can do emergency care by fax and one time only). Till you go by and get the original.

Things needed each time you bring your child.
A change of clothes with close toe shoe on (close toe shoes for saftey reasons).
Infants under 1 year old you need to prepare their bottle for that day and bring their food
Older children over 1 yrs old we feed them here.
diapers, at least 6
wipes
pull up at least 6
bibs
A few Kleenex
I crib small sheet
1 small child size blanket.
Apply any sunscreen or bug spray on them before they get here.

Once you pay for a slot for a time frame NO REFUNDS are given back. If your child was on a waiting list and they call you and you have paid here, or you found somewhere else you can tell them when you can start after your time in up here.
But we DO NOT REFUND MONEY!!
Please Sign here that you have read that there is no money refund! Thank You!__________________________________________________________

Feel free to ask questions when needed.